Neurological Emergencies (0-5%) Complete Flashcards
Status epilepticus
Status epilepticus: _____ min clinical or electrographic seizure activity OR
____ seizures without ______
Refractory status epilepticus: failure of __________
Management:
Don’t forget?
Status epilepticus
Status epilepticus: ≥ 5 min clinical or electrographic seizure activity OR
≥2 seizures without recovery in between
Refractory status epilepticus: failure of benzodiazepine + 1 AED occurs in 30%
of SE patients, 30% die
Management:
CHECK CAPILLARY GLUCOSE –> thiamine 100 mg IV, D50 (50 mL IV)
Status epilepticus: Initial Management
_______ + _______
Status epilepticus: Initial Management
1 Abortive + 1 Maintenance
Refractory Status Epilepticus
Management:
_________________________
_________________________
_________________________
_________________________
Monitor for _____ with _____
Definition of Epilepsy
___________ seizures _____h apart
OR
_________ with _____ % recurrence risk
OR
_______ syndrome
Definition of Epilepsy
≥2 unprovoked seizures >24h apart
OR
1 unprovoked seizure with >60% recurrence risk
OR
Epilepsy syndrome
Epilepsy Classification
Focal:
EEG? ______________
Rx? ______________
Generalized
EEG? ______________
Rx? ______________
Epilepsy Classification
Focal:
EEG? Focal IEDs, slowing
Rx?: Epilepsy surgery
Generalized
EEG?: Generalized spike & wave
Rx?:
- AEDs
- Vagal nerve stimulator
- Ketogenic diet
Seizure vs Syncope vs TIA vs Migraine Aura
Seizure:
Risk of recurrence
Ø After first seizure ~______% risk of recurrence, greatest in first ____y
(treatment lowers ____y recurrence risk but not _______ risk)
Ø _____% if abnormal EEG or MRI
Seizure:
Risk of recurrence
Ø After first seizure ~21-45% risk of recurrence, greatest in first 2y
(treatment lowers 2y recurrence risk but not longterm risk)
Ø ≥ 60% if abnormal EEG or MRI
AEDs:
Which ones to avoid in idiopathic generalized epilepsy?
Why?
Carbamazepine*
Oxcarbazepine*
Phenytoin*
Eslicarbazepine*
Gabapentin*
Why? They can paradoxically worsen seizures
AEDs safe in Pregnancy?
Levetiracetam
Lamotrigine (choose this for associated bipolar disorders)
How to pick a first AED?
Counseling patients with epilepsy
CMA Driving Guidelines:
Ø First seizure, unprovoked: _______ months
Ø Epilepsy: _______ months seizure-free on medication
Ø Medication change: _________ months
CMA Driving Guidelines:
Ø First seizure, unprovoked: 3 months
Ø Epilepsy: 6 months seizure-free on medication
Ø Medication change: 3 months
AEDs:
Adverse effects: “SCARED-P” mnemonic
ØOsteoporosis
ØHyponatremia: __________, __________, __________
ØPsychiatric/irritability: __________
ØStevens-Johnson syndrome: __________, __________, __________, __________
ØPR-prolongation: __________
ØWeight gain: __________
ØWeight loss: __________
ØCognitive impairment: __________, __________
ØSedating: __________, __________
Adverse effects: “SCARED-P” mnemonic
ØOsteoporosis
ØHyponatremia: carbamazepine, oxcarbazepine, eslicarbazepine
ØPsychiatric/irritability: levetiracetam
ØStevens-Johnson syndrome: phenytoin, lamotrigine, carbamazepine, oxcarbazepine
ØPR-prolongation: lacosamide
ØWeight gain: valproate
ØWeight loss: topiramate
ØCognitive impairment: topiramate, clobazam
ØSedating: clobazam, phenobarbital
Guillain-Barré Syndrome
Treatment?
For nonambulatory patients within ______ weeks of symptoms,
_____________________ over ____ days
OR
______________________
_________ NOT recommended in GBS.
No role for sequential or repeat ___________ treatments
For nonambulatory patients within 4 weeks of symptoms,
Intravenous immunoglobulin (IVIg)
2g / kg divided over 2-5 days
OR
Plasmapheresis (PLEX)
Steroids are NOT recommended in GBS.
No role for sequential or repeat IVIg treatments
GBS:
Elective intubation if?
_________ can mimic GBS
Investigation to differentiate?
Acute myelopathy can mimic GBS
Ø MRI whole spine + Gad
– Nerve roots & cauda equina may enhance, also r/o acute myelopathy (mimic)
The typical pattern of neuropathy and Red flags?
Myasthenia Gravis:
Symptoms?
Fatiguable weakness primarily of:
Ocular: ptosis, binocular diplopia, pupil-sparing
Bulbar: dysarthria, dysphagia, chewing fatigue, head drop
Respiratory: orthopnea
Extremities: proximal > distal weakness, and intense fatigue
Myasthenia Gravis:
Investigations?
Investigations
ØFVC/PFTs
ØSerum AChR Ab (±MuSK, LRP4): 80% generalized MG, 50% ocular MG
ØEMG/NCS
ØSFEMG: Single-fibre EMG of frontalis, orbicularis oculi for enhanced jitter (Sn 95%, nonspecific)
ØRNS: Repetitive nerve stimulation for decrement (Sn75% Sp 90%)
ØCT chest to r/o thymoma (10% MG pts)
ØCBC, electrolytes, Cr
ØTSH, CK
Acute Management of myasthenic crisis
___________ (Preferred)
OR
___________
Hold ____________ when intubated (manage airway secretions)
Don’t use _______________
Plasmapheresis (PLEX)
Preferred by consensus opinion for rapidity of action
OR
Intravenous immunoglobulin (IVIG)
2g/kg over 2-5d
Hold pyridostigmine when intubated (manage airway secretions)
High-dose prednisone CAUTION!
<50% transient worsening of respiratory status in 5-10d
Maintenance treatment of myasthenia gravis
Symptomatic?
Disease-Modifying Therapy?
Role of thymectomy in myasthenia gravis
Thymoma + (10%): ___________
Thymoma negative: Elective thymectomy if:
____________
____________
____________
Role of thymectomy in myasthenia gravis
Thymoma + (10%): Refer to thoracic surgery for thymectomy
Thymoma negative: Elective thymectomy if:
Ø <60 years
Ø AChRAb+
Ø Disease duration <5y
Drugs to avoid in myasthenia?
Drugs to avoid in myasthenia:
Ø Anesthetic agents (neuromuscular blockade)
Ø Antibiotics (fluoroquinolones, macrolides, aminoglycosides)
Ø Cardiovascular drugs (beta-blockers, procainamide, quinidine)
Ø Anti-PD-1 monoclonal antibodies (e.g. nivolumab, pembrolizumab)
Ø Botulinum toxin
Ø Chloroquine, Hydroxychloroquine
Ø Magnesium, lithium
Ø Glucocorticoids CAUTION in myasthenic crisis!
Red flags in headache?
Red flags in headache: SNOOP4
Systemic: fever, weight loss, immunosuppression (HIV, steroids, cancer, pregnancy)
Neurological symptoms/signs (meningismus, encephalopathy, papilledema)
Onset thunderclap: peaks <1min
Older > 50y
Pattern Δ, Positional, Pulsatile tinnitus, Precipitated by cough or Valsalva
Headache differentials:
Treatment of status migrainosus
6 spinal cord syndromes
Multiple sclerosis: Typical syndromes
Revised Macdonald criteria for RRMS - Relapsing-remitting Multiple Sclerosis- 2017
Treating MS attacks
Vertigo.
Differentials?
Posterior reversible encephalopathy syndrome
